Author & Consultant/Trainer in Health, Social Care, and Management

‘NICE has published new guidance setting out ‘red flag events’ which warn when nurses in charge of shifts must act immediately to ensure they have enough staff to meet the needs of patients on that ward.

‘Red flag events’ include patients not being provided with basic care such as pain relief or help to visit the bathroom. An appropriate response could be to provide more skilled nurses or increase numbers of staff.

This latest guidance is designed to help ensure safe and efficient nurse staffing levels on hospital wards that provide overnight care for adult patients in England and is in response to concerns about standards of patient care in the aftermath of the Mid Staffs scandal.

The Francis Inquiry and the Berwick report outlined ways in which the NHS can improve care. Both reports raised the issue of staffing levels, with the Francis report explicitly stating that inadequate staffing levels at Mid Staffordshire led to the poor quality of care. The reports identified that NICE should be the lead organisation in the development of guidance for the NHS on staffing levels.

As patients’ needs differ from day to day, there is no single staff number that can be safely and adequately applied across the wide range of wards in the NHS. The guidance committee concluded that when each registered nurse is caring for more than 8 patients this is a signal to check that patients are not at risk of harm. At this point senior management and nursing managers should closely monitor red flag events, analyse safe nursing indicator data and take action if required. No action may be required if patient needs are being adequately met.

Professor Gillian Leng, Deputy Chief Executive and Director of Health and Social Care at NICE said: “Safe staffing is more complex than setting a single ratio. The emphasis should not just be on the available number of staff, it should be on delivering safe patient care and making sure that hospital management and nursing staff are absolutely clear on best practice to do this.”

Miles Scott, Chief Executive Officer, St George’s Healthcare NHS Trust and Chair of the Guideline Development Group, said: “Acute wards see a variety of patients, from appendicitis to broken bones, from young to very old, and each individual has very different needs. This guidance has been trialled in over 100 hospital wards in 14 different hospitals and clearly sets out the factors that must be taken in to account to work out what is the adequate skill level and number of nursing staff required on that particular ward. Safe staffing needs to be about ensuring you have the right staff, in the right place, at the right time, to give patients the care they need and deserve.

Jane Cummings, Chief Nursing Officer for England, said: “Each ward needs the right team of staff to provide high quality care for their patients and their individual needs. This doesn’t happen by accident – it requires an evidence based approach, clinical judgment and regular monitoring, with the flexibility to quickly adapt to changing circumstances. NICE have brought together expert evidence to produce a set of guidelines that hospitals can use to ensure that patients are always at the centre of every staffing decision.”

NICE says that while there may be some upfront costs involved in putting these recommendations into practice, depending on the existing staff levels, this is likely to be offset by the savings that can be achieved through safer care. Potentially over £1 billion can be saved by preventing pressure ulcers, while reducing the number of infections patients get after surgery could save up to £700m a year alone.

Professor Leng added: “The current national cost for nursing staff in acute wards is estimated at around £4 billion. Implementing the NICE guideline is unlikely to have significant financial impact in many trusts, as they may simply need to adapt their processes to work out where nursing staff should be at any given time. Nor will any financial impact be felt in a one year period. Many trusts are already rolling out planned staffing changes, which will spread the cost across a number of financial years. The expected increased training numbers for nursing staff will also see a gradual increase between now and 2017.”

More information

Use the interactive NICE pathway to get fast access to all guidance, resources and related information for safe staffing for nursing.’